Doubtful benefits

A major group of patients who come to us are those with non- communicable diseases being treated elsewhere who just cannot bear the cost of treatment. Of course, most of the extra expenses are a result of multivitamins and latest combination drugs which are expensive.

However, I was quite surprised to meet a well off gentleman who came to me last week. He was diagnosed to have diabetes and hyperthyroidism elsewhere. He was incurring a cost of 7000 INR every month just to purchase the medicines. Doctor consultation costs and blood tests were extra. He had met another doctor who told him that there was no need for so many medicines.

He came for a second opinion.

His original treating doctor was no small man. He was a senior cardiologist in a NABH accredited hospital in a state capital city of our country.

The best I could do was to call up one of my friends in the respective speciality.

The below snap shows the medicines he had with him. In the foreground is the medicines he absolutely needs and behind it are the medicines he could do without, which has not much evidence of significant benefit.

A close up of the medicines we stopped. The protein powder and the sucralfate syrup is included.

Now, this is a patient who can afford to spend 7000 INR. One can only imagine the plight of the poor who are given a similar prescription . . .

Well, I hope you looked at the second snap, which shows the medicines he stopped a bit close . . . In that bunch of medicines, I hope you noticed Tab. Faropenem 200 mg. The gentleman was having it twice a day since the last 10 days. I could not find any evidence of any sort of infection in the papers he had nor did he give any history of the same. 

So much for evidence based medicine and the dangers of antibiotic resistance that we talk about . . . 

Bringing hope . . .

We regularly have patients who give us immense satisfaction at places like Kachhwa. Mrs. PPD was such a patient.

Mrs. PPD came to us in a very serious shape – more serious emotionally than physically. Just 33 years of age, PPD had been diagnosed to have Diabetes Mellitus about 6 years back. She had been running from one doctor to the next since then. She was scared of Insulin shots. Almost all the doctors she met told her the truth - the fact that she needed Insulin to keep her diabetes under control. But PPD was scared.

The depressive nature of PPD brought a sense of doom to her extended household. Her mother-in-law narrated on how the illness seems to have brought a pall of gloom into the home.

PPD came to us about a month back with serious infection. She was depressed and wanted to die. It was a major struggle for us to convince her that she needed insulin injections. Our team did quite a bit of persuasion and prayers to convince her. Initially, she was not ready to self administer the medication.

Over the course of her admission, we discovered that she had bilateral cataract. The issue was about getting the surgery done while the ‘surgery season’ was on. And then there was the spectre of diabetic retinopathy which could dampen the surgery. Of course, someone had went to the extent of telling her that she will not see again that she did not bother to mention about her low vision to us. It was one of our staff who noticed that she was fumbling with things that we realised that her vision was as low as 1/60.

We prayed for her. By God’s grace, from a situation of seriously uncontrolled sugars, the sugar levels were well controlled and she was able to undergo surgery.

Post-surgery, we were all concerned about how much vision she would be able to have. On removing her bandages, we praised God as she told us about how clearer her world has become.

PPD (left with the dark glasses) with her mother in law
(Consent obtained for posting snap)

PPD’s mother narrated on how she has become a lively presence in the house after her treatment. It’s so satisfying to have patients like PPD who appears to have lost all hope for her future. However, we're sure that had it not been for her extended family who was ready to stand with her in the treatment and encourage her, they would not have been able to bring back hope and joy in the house. 

Non-communicable diseases - 'Ottamooli'

Sometime in the middle of last month, the United Nations had convened a high level meeting on Non-Communicable diseases (NCDs). It is praise-worthy that the world has recognised the burden that NCDs poses to communities.

Even in a remote community where I serve, NCDs are turning out into a major force to deal with. Along with diabetes and hypertension, the most recent phenomenon that we had been witnessing is the huge number of young adults and children in whom we are diagnosing Bronchial Asthma. 

Today, in the outpatient department, I diagnosed 6 new cases of bronchial asthma. In the Indian context, one of the most challenging facets in the management of NCDs is the concept of the 'single drug concept' present in Ayurveda. I'm not sure if there is English word for that. In Malayalam it's called 'Ottamooli'

When we explain to the patient that he/she may need to be continuously on some form of treatment for his condition, the family is very much crestfallen. With bronchial asthma, it is a bit easy as I also have it - and most of the time, I take out my Inhaler and show them that I regularly use it. 

Coming to Bronchial Asthma, it is disease with quite a lot of stigma. Couple of weeks, I had a young couple who had brought their 5 year old son whom I diagnosed to have Bronchial Asthma. When I prescribed them an inhaler with a spacer, they did not realize what I had prescribed. When they brought it and came back for helping them use it, the mother started to sob, when I opened the packet and took out the inhaler. 

She told me that if anybody finds her son use it, her son would have difficulty finding a bride when he grows old. Well, it was terrible to hear that. She wanted me to cancel the prescription for the spacehaler and instead give them tablets. According to her, nobody would know that her son is on tablets. The father also ultimately started to beg me to change the prescription. No amount of counselling could help them. 

Coming back to diabetes, the attitude towards finding out a 'ottamooli' prevails. Quite a lot of practitioners have been claiming to bring about a radical cure for the disease. I've had enough patients who have come in a very uncontrolled state of diabetes after having being misled about such treatments.

With the number of patients which we encounter in our outpatient department with conditions such as diabetes, hypertension and chronic lung diseases such as bronchial asthma on the increase, the burden it is going to pose to poor agrarian communities is massive. I wonder what do we have to offer them. Or would it ultimately end up as a major business opportunity to the pharmaceutical industry - there are already signs of such a phenomenon. 

Essential Drugs

Recently, there has been reports of a major study which brought out the fact that cheaper effective drugs are not being used to combat non-communicable diseases in the country.

Although I did not read about this study in 'The Lancet', I’m reminded of the umpteen number of patients that I see with very expensive medicines given for diabetes and hypertension. Couple of hours back, one of the patients’ bystander, BBM whom I discharged today came to me very discretely and wanted to know if the patient needs to continue the drugs which she is taking from elsewhere. I was a bit taken aback as during admission we had asked the patient about previous treatment being taken. The relatives had replied in the negative.

She was admitted with septicemia and urinary tract infection. The treatment has been quite expensive for the family.

Now, here was a relative of the patient whom I had not seen before standing in front of me saying that she had diabetes and hypertension and she was on quite a lot of treatment. She had 3 different medicines for her hypertension, 3 other medicines for her diabetes, one drug for lowering cholesterol, one for lowering triglycerides, couple of vitamin tablets and two drug to prevent platelet aggregation. The total cost of her medicines for one day was about 60 rupees. It was only 3 months since she has started on the treatment and the family was already feeling the pinch.

If you thought that she must have been a very obese lady looking very sick, you are mistaken. She was quite fit and when she got discharged she looked quite fine. Her blood pressure was normal throughout admission and her random blood sugar was a bit on the higher side. We were planning to do a FBS/PPBS sometime during admission which we missed out.  

Well, I did not know what to say to this man. First of all, this family had not mentioned anything about her medical problems during admission and now they want me to take a decision on whether she should continue on her present medicines, almost half which I've no idea about.

BBM was already discharged. Her blood pressures were normal. I’ve asked the family to bring her in after about a week where I would be checking her FBS/PPBS and other parameters. I hope that I would be able to start bit more simple medicines for her when she comes back next week and enable to make her treatment more affordable to the family.